Steven Russell

User Fee Policies to Promote Health Service Access for the Poor: A Wolf in Sheep's Clothing?

An international survey of health service user fee and exemption policies in 26 low- and middle-income countries assessed whether user fee policies were supported by measures that protect the poor. In particular, it explored whether governments were introducing a package of supportive measures to promote service improvements that benefit disadvantaged groups and tackle differential ability to pay through an effective series of exemptions. The results show that many countries lack policies that promote access for disadvantaged groups within user fee systems and quality improvements such as revenue retention at the health care facility and expenditure guidelines for local managers. More significant policy failures were identified for exemptions: 27 percent of countries had no policy to exempt the poor; in contrast, health workers were exempted in 50 percent of countries. Even when an official policy to exempt the poor existed, there were numerous informational, administrative, economic, and political constraints to effective implementation of these exemptions. The authors argue that user fee policy should be developed more cautiously and in a more informed environment. Fees are likely to exacerbate existing inequities in health care financing unless exemptions policy can effectively reach those unable to pay.

Fisherfolk are among groups most at risk of HIV: cross-country analysis of prevalence and numbers infected.

HIV prevalence in some fishing communities in low and middle-income countries is known to be high relative to national average seroprevalence rates. Most of the studies supporting this claim refer to the men involved in fish-catching operations (fishermen). However they acknowledge that the men and women who work in associated occupations such as fish trading and processing are also vulnerable in part because they are often within the fishermen’s sexual networks. This vulnerability stems from the nature and dynamics of the fish trade and fishing lifestyle in which a number of known or hypothesized ‘risk factors’ converge. (excerpt)

Addressing the structural drivers of HIV:a luxury or necessity for programmes?

The social, economic, political and environmental structural factors that increase susceptibility to HIV infection and undermine prevention and treatment efforts continue to pose a challenge. The papers in this series highlight the importance of sustaining those efforts to address the structural drivers of the HIV epidemic, and that initiatives to achieve HIV elimination will only come about through a comprehensive HIV response, that includes meaningful responses to the social, political, economic and environmental factors that affect HIV risk and vulnerability. In the context of declining resources for HIV/AIDS, the papers speak to the need to integrate responses to the structural drivers of HIV/AIDS into future HIV investments, with both initiatives to integrate HIV into broader gender and development initiatives, as well as adaptations of current service models, to ensure that they are sensitive to and able to respond to the broader economic and social responsibilities that their clients face.

Sex after ART:Sexual partnerships established by HIV-infected persons taking anti-retroviral therapy in Eastern Uganda

This paper explores the social contexts that influence the formation and nature of sexual partnerships among people on anti-retroviral therapy (ART). We draw on the findings of a qualitative, longitudinal study of 70 people (36 women and 34 men) who have been participating in a home-based ART programme for over three years in Eastern Uganda. Since initiating ART, 32 (18 men and 14 women) participants reported having had a new partner. Five participants (4 men and 1 woman) renewed relationships with spouses with whom they had been prior to starting ART. Overall, 37 of the 70 participants had had a sexual partner after starting ART. Companionship, material support, social and cultural norms, as well as a desire for sex and children, are drivers of new relationships. The opportunity that ART brings for people to get on with their lives brings with it a reinstatement into a social world that places a value on marriage and child-bearing. The sexual rights of those living with HIV and on ART need to be taken seriously and safer sex facilitated.

Reforming the health sector: towards a healthy new public management

New public management (NPM) ideas have been reflected in the international health sector reform agenda. This paper summarizes the extent and depth of reform in the five countries studied, as reflected in four key policy arrangements, and reviews the various dimensions of capacity which have hindered policy development and implementation. The paper concludes that NPM reforms place demands on government which are not only technically complex but require political leadership, major institutional reform and shifts in organizational culture: it was thus not surprising that none of the case-study countries had undertaken far-reaching NPM reforms in the health sector. Key lessons for capacity strengthening are drawn from the country experiences. Copyright

Expanding antiretroviral therapy provision in resource-constrained settings: social processes and their policy challenges

This editorial considers several broad areas including: how is antiretroviral therapy (ART) affecting the social construction of the disease peoples identities and stigma; how are people adjusting to a new chance of life to living with HIV as a chronic condition and what challenges do they face in rebuilding their social and economic lives; and how is ART delivery affecting the working and personal lives of health workers.

Targeting antiretroviral therapy:Lessons from a longitudinal study of morbidity and treatment in relation to CD4 count in Thailand

The aim of the study was to quantify the incidence of illness and treatment behaviour in relation to CD4 count, age, and gender among a cohort of persons living with HIV/AIDS in Thailand. 464 participants with a CD4 count between 50 and 550 cells/mm3 were followed up for 12 months. Multiple Poisson regression was used to model the adjusted incidence rate ratio of illness and care seeking at different levels. The incidence of morbidity and treatment pattern were significantly different among participants with different CD4 count, age and gender. For example, morbidity incidence was significantly higher among participants with CD4 count of less than 200 cells/mm3, among female participants, and participants aged 35 years or over. Females made significantly higher use of hospital ambulatory care and private clinics than males and males made significantly more use of private pharmacies. The potential opportunity cost of not providing ART to these different groups can be estimated and used to inform further economic evaluation and policy decisions on whether to provide ART at all and which patient groups to prioritise.

Reforming Health Sector Reform

The previous chapter addressed both the capacity problems faced by those case study countries that had considered or introduced specific reforms, and how capacity might best be increased. It left largely unaddressed the fundamental question of the relevance of these reform measures to particular countries, and indeed the relevance of what is widely perceived to be an international health sector reform agenda based on NPM principles. While the evidence that capacity constraints are a severe barrier to the implementation of reforms provides a prima facie case for questioning those reforms, it is also important to address directly the relevance of reforms.

Taking Account of Capacity

The introductory chapter to this book set out a framework for analysing capacity which was used for data collection and analysis in countries. This conceptual framework emphasised: Internal and external aspects of capacity — the distinction between aspects of capacity internal to the implementing organisation such as the skills and systems present in the Ministry of Health, and external aspects of capacity including the broader political, social and economic environment. It was suggested that development of internal capacity needed to be congruent with the external environment; for example, problems would occur if new financial systems developed by the Ministry of Health did not satisfy government-wide financial regulations. The task-specific nature of capacity — for example, the capacities required for government to directly finance and deliver health care may be very different from those required for government to contract out services. An assessment of capacity therefore needs to be linked to the tasks to be performed.

The role of children in their HIV-positive parents' management of antiretroviral therapy in Uganda.

Adjustment to life on antiretroviral therapy (ART) and living with HIV as a long-term chronic condition, pose significant medical, social and economic challenges. We investigated children’s role in supporting HIV-positive parents to self-manage life on ART. Between 2010 and 2012, we conducted a qualitative study using semi-structured interviews with 38 HIV-positive parents who had been on ART for over a year. They were randomly selected from people accessing ART from three delivery sites in Wakiso district, Uganda. Data were analysed thematically. Participants reported children between the ages of 1 and 47 years providing support. Children were a source of happiness, self-worth, encouragement, and comfort. Both younger and older children supported parents’ adherence to treatment through reminding them to take the drugs and honour clinic appointments. Older children provided money to buy medication, food and shelter. Parents reported that the encouragement they received after they disclosed to their children enhanced their survival. After HIV disclosure to their children many of their fears about the future were allayed. Thinking about their children’s future brought hope. However, looking after younger children while on ART could be burdensome since some parents could not work to their full capacity due to reduced physical health. Children are an important resource in their parents’ adjustment to living with HIV while taking ART. There is a need for children to be supported by appropriate policy and other social and health development structures.